Provider Demographics
NPI:1083612774
Name:FIELDS, LARRY S (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:S
Last Name:FIELDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1101 SAINT CHRISTOPHER DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7087
Mailing Address - Country:US
Mailing Address - Phone:606-836-3196
Mailing Address - Fax:606-836-2564
Practice Address - Street 1:1101 SAINT CHRISTOPHER DR
Practice Address - Street 2:SUITE 250
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7087
Practice Address - Country:US
Practice Address - Phone:606-836-3196
Practice Address - Fax:606-836-2564
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY19519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64195191Medicaid
000000191982OtherBLUE CROSS BLUE SHIELD
080172358OtherRAILROAD MEDICARE
OH0536236OtherOHIO MEDICAID
OHF10727432OtherOHIO MEDICARE
OHF10727432OtherOHIO MEDICARE
C69082Medicare UPIN
KY0676503Medicare ID - Type UnspecifiedKY MEDICARE